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BackgroundScientific advances have led to the discovery of novel treatments with high prices. The cost to publicly fund high-cost drugs may threaten the sustainability of drug budgets in different health care systems. In oncology, there are concerns that health-benefit gains are diminishing over time and that the economic evidence to support funding decisions is too limited.MethodsTo assess the additional costs and benefits gained from oncology drugs over time, we used treatment protocols and efficacy results from U.S. Food and Drug Administration records to calculate cost-effectiveness ratios for drugs approved to treat first- and second-line metastatic or advanced breast, colorectal, and non-small cell lung cancer during the years 1994-2013. We assessed reimbursement recommendations reached by health technology assessment agencies in the U.K., Australia, and Canada.ResultsCost-effectiveness ratios were calculated for 50 drugs approved by the U.S. regulator. The more recent approvals were often based on surrogate efficacy outcomes and had extremely high costs, often triple the costs of drugs approved in previous years. Over time, the effectiveness gains have increased for some cancer indications; however, for other indications (non-small cell lung and second-line colorectal cancer), the magnitude of gains in effectiveness decreased. Reimbursement recommendations for drugs with the highest cost-effectiveness ratios were the most inconsistent.ConclusionEvaluation of the clinical benefits that oncology drugs offer as a function of their cost has become highly complex, and for some clinical indications, health benefits are diminishing over time. There is an urgent need for better economic evidence from oncology drug trials and systematic processes to inform funding decisions.Implications for practiceHigh-cost oncology drugs may threaten the ability of health care systems to provide access to promising new drugs for patients. In order to make better drug-funding decisions and enable equitable access to breakthrough treatments, discussions in the oncology community should include economic evidence. This study summarizes the extra benefits and costs of newly approved drugs from pivotal trials during the postgenomic era of drug discovery. The reader will gain an appreciation of the need for economic evidence to make better drug-reimbursement decisions and the dynamics at play in today's oncology drug market.

The issue of timely access to high quality cancer care has heightened in Canada, fueled in part by incidence rates reaching levels where cancer now touches, in some way, the [...]

It may be time to do controlled trials to see if the analgesic ladder proposed by the World Health Organization (WHO) is effective in treating cancer pain. The analgesic ladder is a set of simple guidelines that focuses on cheap, effective analgesics. It was published by WHO in 1986 and more than 250,000 copies have been distributed worldwide. However, a review of the literature revealed that there have only been eight studies to rigorously assess whether the ladder is effective. None of the studies included a control group and half followed fewer than 100 patients. Overall, adequate pain relief was achieved in 69% to 100% of the patients in the studies., Objective.--To perform a systematic review of studies evaluating the effectiveness of the World Health Organization (WHO) analgesic ladder as an intervention for cancer pain management. Data Sources.--Systematic search of MEDLINE from 1982 to 1995, hand search of textbooks and meeting proceedings, reference lists, and direct contact with authors. Study Selection.--Studies of any methodological design were included if they evaluated patients with cancer pain treated according to the WHO analgesic ladder and if the studies provided enough information to estimate the proportion of patients who achieved adequate analgesia with the use of the ladder. The strength of the evidence provided by each study was assessed separately by both authors using current concepts. Data Extraction.--From the hard copy of each study report, the first author's name, publication year, study design, number of dropouts per study, and proportion of patients with adequate analgesia in each study were extracted. Data Synthesis.--Eight studies purporting to evaluate the effectiveness of the WHO ladder were included in the review. Meta-analysis was not performed because the studies were case series with no control groups. The studies had other limitations: none provided information on the conditions in which pain was assessed; two were retrospective; one had short follow-up periods; three had high withdrawal rates; and one had variable follow-up periods. Analgesia was adequate in 69% to 100% of patients analyzed in the studies. Conclusions.--The studies available provide valuable information on the course of cancer pain and its treatment. However, the evidence they provide is insufficient to estimate confidently the effectiveness of the WHO analgesic ladder for the management of cancer pain. Until results from carefully designed controlled trials are available, it would be inappropriate to judge the performance of clinicians, programs, and institutions or to design policies based on such evidence. (JAMA 1995;274:1870-1873)

Quitting smoking at the time of diagnosis may improve the chances for recovery and survival among patients who undergo radiation therapy for head and neck cancer. Smoking cigarettes during radiation therapy may affect the response to treatment or increase the number of side effects in some patients. Among 115 patients who underwent radiation therapy for head and neck cancer, 62 did not smoke or quit smoking at the time of their diagnosis and 53 continued to smoke after their diagnosis. Seventy-four percent of the individuals who quit smoking experienced a complete response to treatment, compared with 45% of those who did not quit smoking. Sixty-six percent of those who quit smoking were alive two years after their diagnosis, compared with 39% of those who did not quit. The chances of recovery and survival increased with the length of time between quitting smoking and treatment.

Abstract Background Cancer program delivery, like the rest of health care in Canada, faces two ongoing challenges: to coordinate a pan-Canadian approach across complex provincial jurisdictions, and to facilitate the rapid translation of knowledge into clinical practice. Communities of practice, or CoPs, which have been described by Etienne Wenger as a collaborative learning platform, represent a promising solution to these challenges because they rely on bottom-up rather than top-down social structures for integrating knowledge and practice across regions and agencies. The communities of practice model has been realized in the corporate (e.g., Royal Dutch Shell, Xerox, IBM, etc) and development (e.g., World Bank) sectors, but its application to health care is relatively new. The Canadian Partnership Against Cancer (CPAC) is exploring the potential of Wenger's concept in the Canadian health care context. This paper provides an in-depth analysis of Wenger's concept with a focus on its applicability to the health care sector. Discussion Empirical studies and social science theory are used to examine the utility of Wenger's concept. Its value lies in emphasizing learning from peers and through practice in settings where innovation is valued. Yet the communities of practice concept lacks conceptual clarity because Wenger defines it so broadly and sidelines issues of decision making within CoPs. We consider the implications of his broad definition to establishing an informed nomenclature around this specific type of collaborative group. The CoP Project under CPAC and communities of practice in Canadian health care are discussed. Summary The use of communities of practice in Canadian health care has been shown in some instances to facilitate quality improvements, encourage buy in among participants, and generate high levels of satisfaction with clinical leadership and knowledge translation among participating physicians. Despite these individual success stories, more information is required on how group decisions are made and applied to the practice world in order to leverage the potential of Wenger's concept more fully, and advance the science of knowledge translation within an accountability framework.

Abstract Background The purpose of this study was to evaluate the role of study quality assessment of primary studies in cancer practice guidelines. Methods Reliable and valid study quality assessment scales were sought and applied to published reports of trials included in systematic reviews of cancer guidelines. Sensitivity analyses were performed to evaluate the relationship between quality scores and pooled odds ratios (OR) for mortality and need for blood transfusion. Results Results found that that whether trials were classified as high or low quality depended on the scale used to assess them. Although the results of the sensitivity analyses found some variation in the ORs observed, the confidence intervals (CIs) of the pooled effects from each of the analyses of high quality trials overlapped with the CI of the pooled odds of all trials. Quality score was not predictive of pooled ORs studied here. Conclusions Had sensitivity analyses based on study quality been conducted prospectively, it is highly unlikely that different conclusions would have been found or that different clinical recommendations would have emerged in the guidelines.